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  1. Ian B Hickie, professor
  1. 1Brain and Mind Research Institute, University of Sydney, Camperdown 2050, NSW, Sydney, Australia
  1. ian.hickie{at}sydney.edu.au

Careful monitoring is needed for adverse effects, particularly in the first month of treatment

Because older people with clinical depression have high rates of concurrent medical illness, particularly cerebrovascular disease, they are at high risk of adverse events from most antidepressants.1 However, given the likelihood of poor functional outcomes and the increased risk of premature death by suicide, vascular disease, accident, or injury, safe and effective interventions are needed.1 2 3 In the linked cohort study (doi:10.1136/bmj.d4551), Coupland and colleagues assess the association between antidepressant treatment and risk of adverse outcomes in older people with depression in primary care.4

Before the 1990s, enthusiasm for drug treatment of depression was tempered by the risks associated with tricyclic antidepressants or monoamine oxidase inhibitors. With the arrival of selective serotonin reuptake inhibitors (SSRIs), which were reported to have far fewer major side effects treatment increased greatly, particularly in primary care settings.5 However, clinical trials had rarely focused on direct comparisons of benefits versus harms in older patients.

Although the relative benefits of new antidepressants are now clearer,6 there are still valid concerns about prescribing to younger7 and older patients. Although the reduction in suicide with the use of antidepressants is evident in older people,8 it has been harder to determine whether increased prescribing may also cause harm.

Coupland and colleagues assessed the effects of antidepressants in 60 706 patients aged 65 and over with a newly diagnosed episode of …

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